Field
The present disclosure generally is related to medical claim management, including web-based management of claims for submission to governmental agencies.
Background
Medicare Part D is a federal program that went into effect Jan. 1, 2006, which subsidizes the costs of prescription drugs for Medicare beneficiaries in the United States. In order for private Medicare Part D plan sponsors to be reimbursed based on this subsidization, health insurers regularly submit claims to the Centers for Medicare and Medicaid Submission (CMS) containing detailed reporting of pharmacy transactions.
In order to process the multitude of claims, CMS requires that the claims be submitted in a specific format called a Prescription Drug Event (PDE) file. A single PDE file may contain thousands of claim records, with each record corresponding to a single claim. When a PDE file, or a claim record of the file, does not meet the stringent CMS requirements, CMS rejects the claim and associates the rejected claim with a PDE “edit” code. PDE edits can occur for a number of reasons, including incomplete information, incorrect information, or duplicate information.
After receiving a PDE file from a claimant, CMS returns a Drug Data Processing System (DDPS) transaction validation response file (a “DDPS file”), which indicates, among other things, which claims in the PDE file were in error. The DDPS file usually includes claim numbers and an edit code associated with the claim number that is associated with the reason for the edit.
For example, CMS may reject a PDE claim because CMS has no record of the beneficiary being enrolled in Part D on the date of service (edit code 705), because the beneficiary is not eligible for a Low Income Cost-sharing Subsidy (LICS) reimbursement (edit code 715), because the indicated prescription is not covered by Medicare Part D (edit code 738), or because of internal CMS issues (edit code 999).
Typically, the various individual Medicare Part D plan sponsors generate their own files and send these files to CMS. However, numerous problems can occur when generating PDE files, resulting in PDE edits from CMS. From the perspective of the various Medicare Part D plan sponsors, PDE edits represent lost revenue from CMS. Further, PDE errors can affect the reputation, business model, credibility, and competitive posture of Part D plan sponsors. Accordingly, minimization of PDE error rate is an important factor in the overall design, function, and profitability of any Part D plan sponsor.
Generally, disclosed herein are systems for managing the claim process including systems for generating more accurate PDE files and for simplifying the tracking and correction of PDE edits.